The Eyelids: Highly Susceptible to Skin Cancer

By Emily Tierney, MD, and C. William Hanke, MD, MPH

The eyelid region is one of the most common sites for nonmelanoma skin cancers. In fact, skin cancers of the eyelid, including basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma, account for five to 10 percent of all skin cancers. Ninety five percent of these tumors are basal cell carcinomas or squamous cell carcinomas.1,2

The rapid rate of skin cancer increase is of great concern to dermatologists and patients alike. Nonmelanoma skin cancers, including basal cell carcinoma and squamous cell carcinoma, have the highest incidence rates of any cancers in the US.3 Also of concern is the rising incidence of melanoma, which is currently the sixth most common cancer for men, the seventh most common for women, and one of only three cancers with an increasing mortality rate in men.

According to the National Cancer Institute, in 2008 there were 62,480 new cases of melanoma and 8,420 deaths.4 It is estimated that 1 in 55 Americans will develop a melanoma in their lifetime and 1 in 5 will develop skin cancer.3

Nonmelanoma skin cancers have low rates overall for spread to lymph nodes and distant sites (metastasis),1,2 but with eyelid skin cancers there is a significant risk for tissue damage to nearby vital ocular structures1,2,5 and even blindness; the skin around the eyelid is thin and contains little subcutaneous tissue,1,2,5 and anatomic connections to the underlying bone in the region facilitate rapid local tumor spread into the nasal and orbital cavities (the area behind the eye).1,2,5 Tumors must be removed to prevent continued growth and invasion into adjacent structures. Early detection is essential, but is often difficult to achieve due to the growth pattern of these tumors, which tend to infiltrate inwards along the deeper layers of the skin and orbital margin; eyelid tumors often grow under the skin for years before presenting on the surface.1,2,5

Basal cell carcinomas and squamous cell carcinomas adjacent to the eye are usually treated with microscopically controlled surgery (Mohs micrographic surgery), due to the tissue-sparing nature of the procedure and high cure rates.1,2

Distribution of Eyelid Skin Cancers

Table 1. Anatomic Distribution of
100 Eyelid Skin Cancers in Indiana
Number % Total
BCC 83 83.0%
SCC 17 17.0%
Total 100
Patients with Eyelid Tumors
GENDER Number % Total
Women 38 38.0%
Men 62 62.0%
Distribution of Eyelid Tumors
ANATOMIC SITE Number % Total
Lower eyelid 44 44.0%
Medial canthus 19 19.0%
Eyebrow 17 17.0%
Upper eyelid 16 16.0%
Lateral canthus 4 4.0%
Total 100

To assess the areas around the eye that are most susceptible to skin cancer - the upper and lower eyelids, eyebrow, inner and outer junction of the eyelid (canthi) and lid margins - we prospectively evaluated 100 patients with skin cancers in the eye region. The specific type of skin cancer, the precise location, and the gender of the patient were recorded.

The majority of eyelid tumors (n=83, 83 percent) were basal cell carcinomas. The study population consisted of 100 patients, 77 of whom had basal cell carcinoma (77 percent) and 23 of whom had squamous cell carcinoma (23 percent). Sixty two patients (62 percent) were male; 38 (38 percent) were female (Table 1).

figure1_eyelidcancerfigure2_eyelidcancer





Figure 1 exhibits the normal anatomy of the eyelid region and Figure 2 illustrates the most common locations for skin cancer on the eyelids: lower eyelid (n=44, 44 percent); medial (inner) canthus (n=19, 19 percent); eyebrow (n=17, 17 percent); upper eyelid (n=16, 16 percent); and lateral (outer) canthus (n=4, four percent) (Table 1). There were no significant gender differences in the allocation of either type of skin cancer or location.

The results are similar to previously published studies on eyelid cancer distribution. For example, in a report in the British Journal of Ophthalmology, the most common sites of eyelid skin cancers were the lower lid (37.6 percent), medial canthus (38.4 percent), eyebrow (9.4 percent), and lateral canthus (7.1 percent).5

Detection and Treatment

Recurrence rates for eyelid skin cancer range from 5-30 percent when managed by standard modalities, including standard surgical excision and radiation therapy.1,2,5 These recurrence rates are some of the highest recorded for skin cancer.1,2,5 Since the risks for local spread are high and reconstruction of the eyelids is complicated by the complex three-dimensional anatomic relationships that need to be restored after tumor removal, awareness of the early signs of eyelid skin cancer is essential.

The presenting signs of eyelid skin cancers are highly variable.2 Given their infiltrative growth pattern, they often present with a scar-like appearance or texture.2 This differs from the typical presentation of nonmelanoma skin cancer as a "rodent ulcer" (a non-healing, bleeding sore).2 In a study at Johns Hopkins School of Medicine, Baltimore, the most common presenting symptoms for skin cancer on the eyelids included a mass, or tumor (42 patients); ulceration, or sore (33 patients); altered appearance (10 patients); a red spot (five patients), and trichiasis, or ingrown eyelashes (two patients).2

As it allows for the total microscopic control of excised tissue, Mohs micrographic surgery is the most effective treatment for these skin cancers.6 Mohs surgery is performed by removing thin layers of affected tissue, freezing them, and microscopically examining the edges and undersurface of each layer using the frozen sections.6,7 The reliability of this method for eyelid skin cancers is attested to by five year cure rates of 99 percent in 1,773 cases of basal cell carcinoma and 98.1 percent in 213 cases of squamous cell carcinoma.8 Also, in Mohs surgery, the minimum amount of tissue necessary is removed. This allows one to achieve the best cosmetic result and maximally preserve function.6-8

Prevention of Eyelid Skin Cancers

Ultraviolet B (UVB) radiation, at 290-320 nanometers (nm, or billionths of a meter on the electromagnetic spectrum) appears to be the most directly carcinogenic of the various UV wavelengths.9 However, recent attention has been given to the role of UVA (320 nm-400 nm) in tumor development and photoaging. Given that 95 percent of the UV radiation that reaches the earth is UVA, photoprotection with a sunscreen protecting against both the UVA and UVB wavelengths is critical.10 For optimal protection, a physical blocker containing zinc oxide or titanium dioxide, and/or chemical blockers such as avobenzone, oxybenzone or MexorylTM should be used.11 Application of sunscreen to the upper and lower eyelids is complicated by potential irritation when sunscreen is inadvertently rubbed into the eye. Thus, people often skip sunscreen application to the eyelids, and UV damage continues to occur.

Many studies have shown a photoprotective effect from both prescription eyeglasses and sunglasses.12 The protective effects of eyeglasses depend on many factors, including the composition and size of the lenses, and the position in which the glasses are worn.11 Sunglasses may be composed of (a) crown glass (good optical glass with a crown-like shape), which absorbs most UVA and UVB; (b) plastic polymethyl methacrylate, which absorbs little or no UV light, or (c) plastic polycarbonate, which absorbs light in the UVB and part of the UVA spectrum (under 380nm).11 The American National Standards Institute (ANSI)'s criteria for sunglasses and fashion eye wear require less than one percent transmission of wavelengths under 310nm. However, these recommendations are not uniformly followed by all manufacturers.11

Rosenthal and colleagues13 studied the effectiveness of 32 pairs of inexpensive sunglasses in filtering UVR. They found that all sunglasses studied transmitted less than two percent of UVB.12 Sunglasses were more effective in blocking UV than prescription eyeglasses,12 but moving the glasses a small distance from the forehead (further out on the nose) resulted in a significant increase in the amount of UV reaching the eye.12 Analysis of epidemiologic data in this study demonstrated also that sunglasses provide a photoprotective effect against both cataracts and periorbital (the area surrounding the eye) basal cell carcinoma.12

Conclusion

The eyelid region is one of the most common sites for nonmelanoma skin cancers, but with early diagnosis and treatment using Mohs micrographic surgery, the prognosis is good, with some recurrence rates below five percent (compared to up to 30 percent with standard surgical excision). Epidemiologic data suggest that wearing sunglasses that block 99-100 percent UV radiation is an important way to prevent cataracts and skin cancers in areas around the eye, and that a broad spectrum, SPF 15+ sunscreen should be applied to the eyelid region as well as to all exposed areas of the body.


Dr. Tierney is currently a Mohs micrographic surgery and procedural dermatology fellow under the direction of Dr. C. William Hanke at St. Vincent Hospital, Carmel, Indiana, at the Laser and Skin Surgery Center of Indiana.

Dr. Hanke is director of the Laser & Skin Surgery Center of Indiana in Carmel, IN. Dr. Hanke is a senior vice president of The Skin Cancer Foundation.


References

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